Speech-Language Pathology Comprehensive Examination Notes

Pediatric Language Development and Early Intervention

• Early Intervention Focus for At-Risk Infants: The primary focus of early language intervention for at-risk infants should be on facilitating communicative intent and establishing the foundational pre-linguistic skills necessary for language development.

• Dialectal Variations: African American Vernacular English (AAVE):

  • Case Study: Fela: Fela is a third-grade student who speaks AAVE and struggles with the Standard American English (SAE) used in her classroom.

  • Rationale for Intervention: Appropriate rationales for providing language intervention for a child like Fela include addressing the impact of language differences on academic performance and ensuring the student has the code-switching skills necessary to navigate SAE environments without devaluing their primary dialect.

  • Dialectal Markers: Common AAVE features include the omission of the possessive 's' (e.g., "that man car"), the use of the invariant 'be' for habitual actions, and final consonant cluster reduction (e.g., "tes" for "test").

• Brown’s Morphemes:

  • Acquisition order of morphemes in young children is determined by both semantic complexity and grammatical complexity rather than frequency of exposure alone.

  • The presence of specific morphemes serves as a key indicator of linguistic development.

• Language Development at the One-Word Stage: Intervention for children at this stage should be strongly influenced by the child's functional needs and the communicative utility of the words selected for targeting.

• 3-Year-Old English Syntax: A monolingual English-speaking child producing utterances like ‐‐‐ "Book read me" or "Me TV see" ‐‐‐ demonstrates a problem with syntactic structure, specifically word order (Subject-Verb-Object patterns).

• Naturalistic Teaching: This approach involves following the child's lead within a natural environment to facilitate spontaneous communication and generalization of skills.

Anatomy, Physiology, and Swallowing Disorders (Dysphagia)

• Neurological Innervation:

  • Larynx and Velum: The primary motor innervation to the larynx and velum is provided by the Vagus Nerve (Cranial Nerve X).

  • Lower Face and Tongue: Sensorimotor integration of the lower face and tongue involves the Trigeminal (CN V), Facial (CN VII), and Hypoglossal (CN XII) nerves.

• Swallowing Mechanics and Structures:

  • Bolus Transit: The transition of the bolus from the oral cavity through the pharynx requires a coordinated sequence of tongue base retraction, velopharyngeal closure, and hyolaryngeal excursion.

  • Vallecular Residue: Consistent post-swallow vallecular residue exceeding $50\%$ of the vallecular height is a significant indicator of reduced tongue base retraction.

  • Upper Esophageal Sphincter (UES): Factors contributing to the opening of the UES include the relaxation of the cricopharyngeus muscle and the mechanical traction exerted by the upward and forward movement of the hyolaryngeal complex.

• Instrumentation:

  • Standard Videofluoroscopic Swallow Study (VFSS): Typically consists of lateral and anterior-posterior (A-P) views to visualize the oral, pharyngeal, and esophageal phases.

  • Fiber-optic Endoscopic Evaluation of Swallowing (FEES): Suitable for evaluating laryngeal function and pharyngeal residue without radiation exposure.

• Case Study: Ms. Brown: A $70$-year-old female admitted after a CVA showing:

  • Left-side neglect.

  • Anosognosia (denial of impairment).

  • Visuospatial problems including prosopagnosia (difficulty recognizing faces).

  • Good auditory comprehension and repetition but poor topic maintenance.

  • Classification: These clinical features are most consistent with Right Hemisphere Brain Damage (RHD).

Adult Neurogenic Disorders: Aphasia, Apraxia, and Dysarthria

• Wernicke’s Aphasia Case Analysis:

  • Case Study: Ms. Williams: A $75$-year-old woman following a CVA.

  • Symptoms: Intact grammatical structure and normal prosody, but sentences are meaningless (jargon) with nonsensical paraphasic errors. Poor repetition and naming, poor awareness of deficits (anosognosia), and excessive talking (logorrhea).

  • Lesion Location: Posterior superior temporal lobe (Wernicke's area).

• Apraxia of Speech (AOS) vs. Dysarthria:

  • AOS: Characterized by inconsistent errors, groping for articulatory postures, and intact automatic speech compared to impaired volitional speech.

  • Dysarthria: Characterized by consistent errors, muscle weakness, and often associated with atrophy or fasciculations (specifically in Flaccid Dysarthria).

• Amyotrophic Lateral Sclerosis (ALS):

  • A $42$-year-old client with ALS presents with progressive severe dysarthria, imprecise articulation, bilateral lingual weakness, fasciculations, and hypernasality.

  • Communication Strategy: As the disease is progressive, the most effective strategy to improve communication is often the early introduction of Augmentative and Alternative Communication (AAC).

• Cerebellar Involvement: Common symptoms include ataxia, dysmetria, and "scanning speech" (excess and equal stress).

• Anoxic Encephalopathy: Long-term impairments following anoxia often significantly affect memory and executive functioning.

Audiology and Hearing Rehabilitation

• Speech Reception Threshold (SRT): A measurement used to determine the lowest intensity level at which an individual can recognize $50\%$ of speech stimuli, typically spondee words.

• Sensorineural Hearing Loss in Infants: The major component of an audiologic rehabilitation program for infants with moderate sensorineural loss is early fitting of amplification (hearing aids) and providing a language-rich environment.

• Cleft Palate and Hearing: Hearing loss in infants with cleft palate is most frequently related to Eustachian tube dysfunction, leading to recurrent otitis media and conductive hearing loss.

• Environmental Sound Exposure: A single exposure for several hours to continuous music at $100\,dB\,SPL$ is likely to produce a temporary threshold shift (TTS).

• Impedance/Immittance Measurements: To control overreferral in school screenings, the SLP should ensure that equipment is calibrated regularly and that screenings are timed to avoid testing immediately after a child has had a cold or upper respiratory infection.

Research Methodology and Vocal Loudness Study

• Watson and Hughes (2006) Study Analysis:

  • Purpose: To examine the relationship of vocal loudness to prosodic Variables ($F0$ declination and final-word lengthening) that aid listeners in parsing information.

  • Participants: $10$ young, healthy women.

  • Independent Variables: Loudness levels (normal, twice-normal, and half-normal loudness).

  • Dependent Variables: $F0$ declination (resetting at sentence start) and duration (final-word lengthening).

  • Results: A statistically significant increase in $F0$ declination (resetting) and final-word lengthening from half-normal to twice-normal loudness conditions.

  • Cautionary Note: The authors remain cautious because the study used healthy adults; it is uncertain if the same effects (improved communicative effectiveness) apply to individuals with dysarthria until tested on that specific population.

• Variables in Research:

  • Perturbation: Measures such as jitter (frequency perturbation) and shimmer (amplitude perturbation) determine the amount of noise or irregularity in the voice.

Speech Sound Disorders and Phonology

• Phonological Error Patterns:

  • Stopping: Replacing fricatives or affricates with stop consonants (e.g., [t] for /s/).

  • Gliding: Replacing liquids with glides (e.g., [w] for /r/).

  • Fronting: Replacing back sounds with front sounds (e.g., [t] for /k/).

  • Final Consonant Deletion: Omission of the final consonant in a word.

• Phonological Awareness Treatment: Intensive phonemic-awareness treatment is effective for children who struggle with literacy, as reading development is closely tied to the ability to manipulate the sound structure of language.

• Case Study: Michael (32 months):

  • Presentation: History of otitis media, gestures for communication, expressive language delay, inconsistent groping in speech imitation, and metathesis (switching of sounds).

  • Signs of: The profile (groping, sequencing errors, inconsistency) is highly suggestive of Childhood Apraxia of Speech (CAS).

Clinical Practice and Ethics

• Caseload Management:

  • If a state sets a maximum caseload at $65$ and a clinician is at $64$ with a waiting list of $10$, the clinician must not enroll students in a manner that violates legal mandates or ethical standards regarding service quality. The most appropriate action is to formally notify the administration of the legal/ethical ceiling and advocate for more staffing.

• Patient Confidentiality (HIPAA): The goal of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure the privacy and security of health information while allowing the flow of information necessary for high-quality health care.

• Clinical Judgment and Counseling: When counseling parents about articulation, developmental norms can be cited to illustrate whether a child's errors are age-appropriate or require intervention. For a disfluent $4$-year-old (e.g., Molly), if the disfluencies are physically relaxed and within normal rates (e.g., $2$ per $100$ words), monitor-only approaches may be appropriate.

Questions & Discussion

• Question: What constitutes the primary concern for a client with poor oral control of liquids, coughing, and history of pneumonia?

• Answer: The initial action should be a referral for a medical evaluation of swallowing (such as a VFSS) to assess aspiration risk and physiological cause.

• Question: How should a clinician address a client's f/v, ʃ/ʒ, and s/z errors?

• Answer: Remediation should focus on the feature of voicing, as the only difference between these pairs is the presence of vocal fold vibration.

• Question: Which muscle is primarily responsible for vocal fold abduction?

• Answer: The posterior cricoarytenoid muscle.